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This is VAERS ID 995147

History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 995147
VAERS Form:2
Age:88.0
Sex:Male
Location:Unknown
Vaccinated:2020-12-23
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Chills, Death, Erythema, Fatigue, Injection site pain, Pain in extremity, Pyrexia, General physical health deterioration, Laboratory test normal, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Lab tests after MODERNA COVID-19 vaccine: ALL NEGATIVE Orders for date: 01/19/2021 Test Urgency Status Lab NASAL SWAB NASAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test Complete 01/19/2021 12:43 Orders for date: 01/14/2021 Test Urgency Status Order NASAL SWAB NASAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test Complete 01/14/2021 15:59 Orders for date: 01/11/2021 Test Urgency Status Lab NASAL SWAB NASOPHARYNGEAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test complete 01/11/2021 12:27 Orders for date: 01/07/2021 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX zzCOVID-19 (M2000)ROUTINE Test Complete 01/11/2021 17:01 Orders for date: 01/04/2021 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX zzCOVID-19 (M2000)ROUTINE Test Complete 01/08/2021 07:34 Orders for date: 12/28/2020 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX COVID-19 DIAGNOSTIC PANEL (BIOFIRE) ROUTINE Test Complete 12/28/2020 13:58 PCR 20 1403 Most recent med list prior to patient''s death: INPT ACETAMINOPHEN 650 MG RTL SUPP (Status=Active) 650MG RCT FOUR TIMES A DAY AS NEEDED Fever. Give PR if unable to take PO ORDER LAST ACTION: 12/29/20 16:37 GIVEN ALBUTEROL 3/IPRATROP 0.5MG/3ML INHL 3 ML INHALE 1 VIAL IN NEBULIZER BY ORAL INHALATION FOUR TIMES DAILY AS NEEDED COPD, MED HAS LARGE SUPPLY INPT BISADODYL 10MG RTL SUPP (Status=Active) 10MG RCT EVERY 72 HOURS AS NEEDED Constipation. Give if MOM ineffective ORDER LAST ACTION: 02/26/20 18:11 GIVEN INPT LORAZEPAM 2MG/ML INJ. 1 ML (Status=Active) 0.5MG(0.25 ML) SUBCUTANEOUSLY EVERY FOUR HOURS AS NEEDED End of life agitation or anxiety INPT MILK OF MAGNESIA 30 ML UD (Status=Active) 30ML BY MOUTH DAILY AS NEEDED CONSTIPATION ORDER LAST ACTION: 01/07/21 15:09 GIVEN INPT MORPHINE SO4 4MG/ML INJ PFS (Status=ACTIVE) 4MG/ML IV EVERY ONE HOUR AS NEEDED if needed for end of life restlessness, air hunger, pain. ORDER LAST ACTION: 01/19/21 11:15 GIVEN POLYETHYLENE GLYCOL 3350 ORAL PWDR TAKE 17 GM (ONE CAPFUL) BY MOUTH DAILY AS NEEDED constipation. MED HAS LARGE SUPPLY
CDC 'Split Type':

Write-up: Death Narrative: Patient received the first COVID-19 dose on 12/23. Afterwards, patient complained of localized pain on L deltoid area where the vaccine was administered; his temperature was 98.1 F. On 12/26-27, staff reported that patient appeared more fatigued than usual and was shivering on 12/27, which seized after blanket was given. On 12/28, patient presented with fever (Tmax 100.2 F) and acetaminophen was administered for alleviation of fever. ADR was reported for the fever on 12/29. Patient continued to decline and was placed back on hospice care on 12/29; on 12/30. the symptoms reported on nursing note include erythema and pain on whole L arm. Lidocaine was applied. Patient''s family and provider mutually agreed not to administer the second dose of vaccine. He continued to decline and was started on end-of-life care around 1/4 and passed on 1/20 1417.


Changed on 5/7/2021

VAERS ID: 995147 Before After
VAERS Form:2
Age:88.0
Sex:Male
Location:Unknown
Vaccinated:2020-12-23
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Chills, Death, Erythema, Fatigue, Injection site pain, Pain in extremity, Pyrexia, General physical health deterioration, Laboratory test normal, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Lab tests after MODERNA COVID-19 vaccine: ALL NEGATIVE Orders for date: 01/19/2021 Test Urgency Status Lab NASAL SWAB NASAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test Complete 01/19/2021 12:43 Orders for date: 01/14/2021 Test Urgency Status Order NASAL SWAB NASAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test Complete 01/14/2021 15:59 Orders for date: 01/11/2021 Test Urgency Status Lab NASAL SWAB NASOPHARYNGEAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test complete 01/11/2021 12:27 Orders for date: 01/07/2021 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX zzCOVID-19 (M2000)ROUTINE Test Complete 01/11/2021 17:01 Orders for date: 01/04/2021 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX zzCOVID-19 (M2000)ROUTINE Test Complete 01/08/2021 07:34 Orders for date: 12/28/2020 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX COVID-19 DIAGNOSTIC PANEL (BIOFIRE) ROUTINE Test Complete 12/28/2020 13:58 PCR 20 1403 Most recent med list prior to patient''s death: INPT ACETAMINOPHEN 650 MG RTL SUPP (Status=Active) 650MG RCT FOUR TIMES A DAY AS NEEDED Fever. Give PR if unable to take PO ORDER LAST ACTION: 12/29/20 16:37 GIVEN ALBUTEROL 3/IPRATROP 0.5MG/3ML INHL 3 ML INHALE 1 VIAL IN NEBULIZER BY ORAL INHALATION FOUR TIMES DAILY AS NEEDED COPD, MED HAS LARGE SUPPLY INPT BISADODYL 10MG RTL SUPP (Status=Active) 10MG RCT EVERY 72 HOURS AS NEEDED Constipation. Give if MOM ineffective ORDER LAST ACTION: 02/26/20 18:11 GIVEN INPT LORAZEPAM 2MG/ML INJ. 1 ML (Status=Active) 0.5MG(0.25 ML) SUBCUTANEOUSLY EVERY FOUR HOURS AS NEEDED End of life agitation or anxiety INPT MILK OF MAGNESIA 30 ML UD (Status=Active) 30ML BY MOUTH DAILY AS NEEDED CONSTIPATION ORDER LAST ACTION: 01/07/21 15:09 GIVEN INPT MORPHINE SO4 4MG/ML INJ PFS (Status=ACTIVE) 4MG/ML IV EVERY ONE HOUR AS NEEDED if needed for end of life restlessness, air hunger, pain. ORDER LAST ACTION: 01/19/21 11:15 GIVEN POLYETHYLENE GLYCOL 3350 ORAL PWDR TAKE 17 GM (ONE CAPFUL) BY MOUTH DAILY AS NEEDED constipation. MED HAS LARGE SUPPLY
CDC 'Split Type':

Write-up: Death Narrative: Patient received the first COVID-19 dose on 12/23. Afterwards, patient complained of localized pain on L deltoid area where the vaccine was administered; his temperature was 98.1 F. On 12/26-27, staff reported that patient appeared more fatigued than usual and was shivering on 12/27, which seized after blanket was given. On 12/28, patient presented with fever (Tmax 100.2 F) and acetaminophen was administered for alleviation of fever. ADR was reported for the fever on 12/29. Patient continued to decline and was placed back on hospice care on 12/29; on 12/30. the symptoms reported on nursing note include erythema and pain on whole L arm. Lidocaine was applied. Patient''s family and provider mutually agreed not to administer the second dose of vaccine. He continued to decline and was started on end-of-life care around 1/4 and passed on 1/20 1417.


Changed on 5/14/2021

VAERS ID: 995147 Before After
VAERS Form:2
Age:88.0
Sex:Male
Location:Unknown
Vaccinated:2020-12-23
Onset:2021-01-20
Submitted:0000-00-00
Entered:2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Chills, Death, Erythema, Fatigue, Injection site pain, Pain in extremity, Pyrexia, General physical health deterioration, Laboratory test normal, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Lab tests after MODERNA COVID-19 vaccine: ALL NEGATIVE Orders for date: 01/19/2021 Test Urgency Status Lab NASAL SWAB NASAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test Complete 01/19/2021 12:43 Orders for date: 01/14/2021 Test Urgency Status Order NASAL SWAB NASAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test Complete 01/14/2021 15:59 Orders for date: 01/11/2021 Test Urgency Status Lab NASAL SWAB NASOPHARYNGEAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test complete 01/11/2021 12:27 Orders for date: 01/07/2021 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX zzCOVID-19 (M2000)ROUTINE Test Complete 01/11/2021 17:01 Orders for date: 01/04/2021 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX zzCOVID-19 (M2000)ROUTINE Test Complete 01/08/2021 07:34 Orders for date: 12/28/2020 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX COVID-19 DIAGNOSTIC PANEL (BIOFIRE) ROUTINE Test Complete 12/28/2020 13:58 PCR 20 1403 Most recent med list prior to patient''s death: INPT ACETAMINOPHEN 650 MG RTL SUPP (Status=Active) 650MG RCT FOUR TIMES A DAY AS NEEDED Fever. Give PR if unable to take PO ORDER LAST ACTION: 12/29/20 16:37 GIVEN ALBUTEROL 3/IPRATROP 0.5MG/3ML INHL 3 ML INHALE 1 VIAL IN NEBULIZER BY ORAL INHALATION FOUR TIMES DAILY AS NEEDED COPD, MED HAS LARGE SUPPLY INPT BISADODYL 10MG RTL SUPP (Status=Active) 10MG RCT EVERY 72 HOURS AS NEEDED Constipation. Give if MOM ineffective ORDER LAST ACTION: 02/26/20 18:11 GIVEN INPT LORAZEPAM 2MG/ML INJ. 1 ML (Status=Active) 0.5MG(0.25 ML) SUBCUTANEOUSLY EVERY FOUR HOURS AS NEEDED End of life agitation or anxiety INPT MILK OF MAGNESIA 30 ML UD (Status=Active) 30ML BY MOUTH DAILY AS NEEDED CONSTIPATION ORDER LAST ACTION: 01/07/21 15:09 GIVEN INPT MORPHINE SO4 4MG/ML INJ PFS (Status=ACTIVE) 4MG/ML IV EVERY ONE HOUR AS NEEDED if needed for end of life restlessness, air hunger, pain. ORDER LAST ACTION: 01/19/21 11:15 GIVEN POLYETHYLENE GLYCOL 3350 ORAL PWDR TAKE 17 GM (ONE CAPFUL) BY MOUTH DAILY AS NEEDED constipation. MED HAS LARGE SUPPLY
CDC 'Split Type':

Write-up: Death Narrative: Patient received the first COVID-19 dose on 12/23. Afterwards, patient complained of localized pain on L deltoid area where the vaccine was administered; his temperature was 98.1 F. On 12/26-27, staff reported that patient appeared more fatigued than usual and was shivering on 12/27, which seized after blanket was given. On 12/28, patient presented with fever (Tmax 100.2 F) and acetaminophen was administered for alleviation of fever. ADR was reported for the fever on 12/29. Patient continued to decline and was placed back on hospice care on 12/29; on 12/30. the symptoms reported on nursing note include erythema and pain on whole L arm. Lidocaine was applied. Patient''s family and provider mutually agreed not to administer the second dose of vaccine. He continued to decline and was started on end-of-life care around 1/4 and passed on 1/20 1417.

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